ANNUAL SAFETY PROGRAM AUDIT FORM FOR FISCAL YEAR 2014 (JULY 2014 TO JUNE 2015)

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1 ANNUAL SAFETY PROGRAM AUDIT FORM FOR FISCAL YEAR 2014 (JULY 2014 TO JUNE 2015) Please fill out this Self-Evaluation and return to Safety Counselling, Inc. at 3207 Matthew NE, Albuquerque, NM 87107, by (Friday) July 31 st, 2015 in order to complete your Annual Audit requirements. Date Annual Audit Completed: Municipality Name: Municipality Office Contact: Name of Safety Coordinator: Person Completing Form: Title: Phone Number: ( _) _- Total Number of Employees = F.T. = P.T. = Ten key components of a strong safety program are listed below (see A - J). Complete only the column that BEST describes your Municipality s performance. A. Commitment Review documents such as policy statements, Municipality surveys or survey results on safety, employee suggestion letters, and financial records showing safety expenditures (e.g., cancelled checks or invoices). Participates in safety program Participates in safety program Sets objectives for safety Requires feedback on safety Requires feedback on program program Provides necessary funds Provides funds for safety Includes safety as part of Municipality-wide performance appraisals Supports safety Provides funds for safety activities Needs analysis is used to set safety program goals/objectives An action plan is developed to accomplish goals/objectives Feedback is required from those assigned tasks Audits are made to assess action plan effectiveness Long and short term goals are set Safety program goals and objectives are set annually Employees are aware of the goals and objectives Feedback is required from those assigned tasks Informal goals are set for accomplishment through the safety program Results are discussed at least annually

2 B. Written Safety and Health Program Review documents, such as policy statements, safety manuals, and letters from management regarding safety. Safety policy Is in writing Is known to all employees Is part of safety manual Defines purpose and scope of safety program Emphasizes employer approach Is signed and supported by top person(s) in Municipality Safety policy Is in writing Has not been explained to employees, but is posted Authorizes loss prevention activities Safety policy exists Responsibility for safety Defined for everyone in Municipality In writing and part of safety manual Supervisors/foremen have key responsibilities Safety rules are in writing and are communicated to all employees Safety rules are concise and easy to understand Safety rules are enforced equally among all employees Safety rules are updated on a regular basis Subcontractors must follow safety rules Responsibility for safety Defined for everyone in Municipality Is not in writing Supervisors/foremen have key responsibilities Safety rules are in writing and are communicated to all employees Copies of safety rules are posted or available to all employees Supervisors enforce most of the safety rules Subcontractors must follow safety rules Responsibility for safety rests solely with designated safety coordinator There are some general safety rules Safety rules are enforced most of the time Safety rules have not been updated within past two years Assessments made to determine PPE needs Employees trained in use and Approved PPE used PPE provided for employees Employees aware of disciplinary consequences of not using PPE PPE needs assessed annually PPE is provided and use is required Employees trained in use and Employees informed of PPE requirements for each job PPE is provided and its use encouraged Some training is given in use and Municipality has a written substance abuse policy Municipality policy contains strict rules regarding drug and alcohol use Municipality does drug testing for prehire, post-accident and for cause Municipality keeps counseling and testing records Municipality has an Employee Assistance Program Municipality has substance abuse verbiage in Municipality policy Supervisors are trained in hazards of drugs and alcohol on the job Municipality has policy

3 Fund average mod rate. EMR is at or below Fund Average for three most recent years. Employer reviews the costs of accidents and how the EMR affects the Municipality. Maintains OSHA Log-Forms 300 and 300A according to OSHA requirements. C. Experience Modification Rate (EMR) EMR is at or below Fund Average for at least one of the three most recent years. The cost of accidents is reported to the administrator. Maintains OSHA Log-Forms 300 and 300A according to OSHA requirements. EMR is at or below the Fund average mod rate for least one of the three most recent years. Maintains OSHA Log-Forms 300 and 300A according to OSHA requirements. D. Safety Meetings Review documents such as meeting agendas, notes, minutes where safety items are noted, copies of toolbox talks. Include topics and sign-in sheets. Employer conducts weekly supervisor meetings where safety is on the agenda Employer gives an overview of safety activity Serious accidents are reviewed Meetings held weekly Conducted by supervisors Attendance and topic documentation kept Employees participate Employer attends occasionally At least monthly supervisor meetings are held with supervisors where safety is on the agenda Supervisors give a status report on job site safety activities Serious accidents are reviewed Supervisors hold meetings at least monthly Attendance and topic documentation kept Occasional meetings are held with supervisors at which safety is on the agenda Supervisors are given safety information Serious accidents may be reviewed Employer conducts meetings with all employees less than once a month E. Pre-Task Planning Review documents relating to job safety and/or job hazard analysis sheets, Project checklists. Pre-task plans are required. A check list is used by the supervisor to assure all exposures are considered Necessary equipment is provided and precautions are taken prior to or at the start of the job, not after problems have been encountered Supervisors are trained in planning for safety Pre-task planning required prior to mobilization Safety equipment and safety procedures are provided when needed Training in pre-task planning is not required A check list is used as a guide No formal pre-task planning program but some planning is done No check list is used in preplanning

4 F. New Employee Orientation Review documents such as orientation agendas and program materials, class rosters, safety manuals and/or employee handbooks. Formal orientation program is in effect for all new or transferred employees Records maintained showing date, person doing orientation and items covered Orientation includes training on safety rules, GHS: Haz. Com, major job hazard exposures, PPE, and emergency reporting procedures Employer concern for safe job performance is stressed Employee signs record sheet Orientation that includes information on safety is given to new employees Documentation showing items covered is maintained Orientation includes training on safety rules, GHS: Haz. Com, major job hazard exposures, PPE, and emergency reporting procedures Job safety requirements are stressed Orientation is given to employees but no training records are maintained G. Safety Training Review safety training records. (Both for employees and supervisors if separate) Based on training needs assessment, formal safety training is provided and documented in areas such as hazard recognition, first aid/cpr, hazard/standard specific OSHA topics, GHS: Haz. Com, heavy equipment safety and trade specific safety (such as electrical safety) Formal safety training conducted by competent or qualified safety instructors Employee training comprehension/ understanding is verified and documented Supervisory training includes: First Aid/CPR Hazard Recognition GHS: Haz Com Emergency Reporting Procedures OSHA 10 Hour or Greater Conducting Meetings Supervisory Skills Accident Investigation Job Safety Analysis Pre-Task Planning Train-the-trainer Safety Inspections Human Relations Municipality has in-house facilities for training or has good outside training source Professional development courses offered Some formal safety training provided and documented in areas such as first aid/cpr, GHS: Haz. Com and hazard recognition Formal training needs assessment conducted for workforce Informal safety training conducted by competent or qualified safety instructors Employee training comprehension/ understanding is verified and documented Most supervisors receive training in: Hazard Recognition GHS: Haz Com First Aid/CPR Emergency Reporting Procedures Human Relations Supervisory Skills Accident Investigation Job Site Safety Inspections Formal safety training, with verifiable records provided in hazard recognition and GHS: Haz. Com Some informal safety training provided for categories found in far left column Some supervisors are sent to outside training courses

5 H. Accident Investigation Review documents such as investigation reports, near miss forms, recommendation/corrective action reports and materials the Municipality publishes following an accident. Accidents and near misses are investigated by site supervisor All supervisors are trained in the techniques of accident investigation Reports are completed for all accidents Employer reviews all accidents that exceed a set cost The basic causes of all accidents are determined Information learned is shared with all departments There are follow-up steps to assure corrective action is taken All accidents are investigated with a report written Supervisors are trained to make Employer reviews all investigation reports Information on "serious" incidents is shared with employees in all departments Informal are made with no written report Some supervisory personnel know how to investigate an accident Information gained is not shared Persons other than the site supervisor conduct most I. Performance Audits (Performance audits are not site inspections, but audits to evaluate segments (or all) of a safety program.) Review documents such as quality improvement materials, safety benchmarking reports, reports of an activity that was modified and its safety-related results. Safety program is reviewed at least semi-annually to determine if it is producing desired results Criteria against which performance is measured are established Results of performance review become part of overall rating of supervisors Strong points and shortcomings are discussed with individual supervisors Safety program is reviewed annually to determine if it is producing desired results Performance criteria exist for more than half of the areas measured Results are discussed with individuals and departments Subjective review of safety activities made to judge if they are effective Rating given to each area audited J. Employee Participation Review documents including copies of programs in safety manuals, employee policies and procedures manuals, training records, safety toolbox talks sign-in sheets, PTP s, employee incentive programs and employee suggestion boxes. Employee participation program in place Supervisors trained to facilitate employee participation Procedures set up for employees to participate in activities (e.g., see next column) ranging from training to accident Supervisors trained to facilitate employee participation Employees encouraged to participate in tool box talks, hazard recognition/reporting, site inspections, safety rule development/revision, new hire & formal safety training, and accident Employee participation is encouraged Information is given to supervisors on how to involve employees Employee suggestion/ comment program implemented